FIELD OF THE INVENTION
This invention relates to pharmaceutical compositions comprising novel intravenously injectable immune serum globulin, to a process for its production and to its use to administer immune serum globulin intravenously for human therapy.
Intramuscularly injectable gamma globulin preparations are known. One such product is "HYPER-TET" (Cutter Laboratories, Inc., Berkeley, Calif.).
The usual intramuscular gamma globulin preparations cannot safely be administered intravenously because such administration causes an unacceptably high incidence of reactions, especially in agammaglobulinemic recipients. These reactions have been associated with a decrease in serum complement levels, apparently caused by complement binding by the administered gamma globulin. S. Barandun et al., Vox Sang. 7, 157-174 (1962). The ability of gamma globulin to bind complement, termed anticomplementary, is greatly increased as a result of denaturation brought about during the fractionation procedure, in particular by aggregation to high molecular weight species. The complement binding mechanism of these aggregates appears to be identical to that of antigen-antibody complexes. D. M. Marcus, J. Immunol. 84, 273-284 (1960). When the aggregates are removed by ultracentrifugation at 100,000 x gravity, a product low in anticomplement activity is obtained which is well tolerated upon intravenous injection. Barandun et al., supra.
Several approaches have been taken to the problem of rendering gamma globulin safe for intravenous administration. All of these are dependent on eliminating its anticomplement activity. Ultracentrifugation (cited above) is technically unfeasible, and the product so derived regains its anticomplement activity upon storage. Treatment of gamma globulin with the enzyme pepsin at pH 4.0 results in proteolytic cleavage of the molecule to give a fragment of about 10,000 molecular weight which has a sedimentation coefficient in the ultracentrifuge of about 5S,A. Nisonoff et al., Science, 132, 1770-1771 (1960). Even though this surviving fragment retains bivalent antibody activity and lacks anticomplement activity and is well tolerated and efficacious in intravenous administration, W. Baumgarten, Vox Sang. 13, 84 (1967), the therapeutic effect provided is of unacceptably short duration since it is rapidly excreted, having a circulating half-life of only 18 hours, perhaps somewhat longer in agammaglobulinemic patients, compared to 19.8 days for unmodified gamma globulin. E. Merler et al., Vox Sang. 13, 102 (1967); B. Jager, Arch. Intern. Med. 119, 60 (1967). Although the much reduced half-life of pepsin treated gamma globulin is probably due in part to the drastic reduction in size of the molecule, there are indications that the rate of catabolism of gamma globulin is related to specific properties of the portion of the molecule digested by pepsin. J. L. Fahey et al., J. Exper. Med., 118, 1845-1868 (1963). This portion of the molecule remains intact in the present invention. An additional disadvantage of the pepsin treatment procedure is that the pepsin which remains present is of animal origin and can stimulate antibody production, particularly upon repeated administration. C. Blatrix et al., Presse Med. 77, 635-637 ( 1969). The use of plasmin of human origin avoids this difficulty and is the basis of a different process for preparation of intravenous gamma globulin.
Treatment of gamma globulin with human plasmin results in cleavage into three components of about 50,000 molecular weight. J. T. Sgouris, Vox Sang. 13, 71 (1967). When sufficiently low levels of plasmin are used, only about 15 percent of the molecules are cleaved, with 85 percent remaining as intact gamma globulin. Sgouris, supra. The intact gamma globulin remaining undigested shows little anticomplement activity and has been administered intravenously without adverse reactions. J. Hinman et al., Vox Sang. 13, 85 (1967). The material thus prepared appears to retain in vitro and in vivo protective activity. F. K. Fitzpatrick, Vox Sang, 13, 85 (1967). One disadvantage of this approach is that the plasmin cannot be completely removed. Thus, degradation continues even when the material is stored at 4.degree. C.
Incubation of gamma globulin at pH 4.0 at 37.degree. C. for various lengths of time has been observed to reduce the anticomplement activity to low levels. It has been suggested that this result may arise from a small quantity of serum enzyme present as an impurity in the gamma globulin. Blatrix et al., supra. As with the plasmin treated gamma globulin, this "pH 4.0 gamma globulin" has been found to regain anticomplement activity, upon storage, at an unpredictable rate, so that it is necessary to assay anticomplement activity before administration to a patient. J. Malgras et al., Rev. Franc. Trans., 13, 173 (1970).
Both plasmin treated gamma globulin, Hinman et al., supra, and pH 4.0 gamma globulin, H. Koblet et al., Vox Sang. 13, 93 (1967); J. V. Wells et al., Austr. Ann. Med. 18, 271 (1969); Barandun et al., Monogr. Allergy, Vol. 9, 39-60 (1975), Barandun et al., Vox Sang., Vol. 7, 157-174 (1962), have shorter half-lives in vivo than unmodified gamma globulin. For example, the half-life in normal patients of pH 4.0 gamma globulin is about 14 days, Koblet et al., supra, while the plasmin treated material shows a half-life of 16 days, Merler et al., supra.
The Centre National de Transfusion Sanguine (C.N.T.S.) in Paris has, by careful fractionation and filtration of gamma globulin from selected fresh plasma, produced an intravenously injectable gamma globulin with low anticomplement activity. Blatrix et al., supra; ibid., Presse Med., 77, 159-161 (1969); M. Steinbuch et al., Vox Sang. 13, 103 (1967). It is apparently not totally devoid of anticomplement activity, as it must be administered carefully and reactions do occur in some patients. Cortisone may be given prior to injection to eliminate these reactions, but the apparent incomplete removal of anticomplement activity would seem to be detrimental to its widespread use.
The effects on anticomplement activity of reduction of disulfide linkages of gamma globulin followed by reaction with a blocking agent has been investigated in the prior art. S. Barandun et al., supra, found that treatment of a 7 percent solution of gamma globulin with 0.2 M cysteamine, followed by 0.2 M iodoacetamide, resulted in almost complete loss of anticomplement activity whereas treatment with cysteamine or iodoacetamide alone did not significantly decrease anticomplement activity. Because of the toxicity of iodoacetamide, these investigators did not pursue this approach to an intravenously injectable gamma globulin.
A modified immune serum globulin was described in U.S. Pat. No. 3,903,262. The immune serum globulin was rendered intravenously injectable by first reducing to --SH groups a portion of the disulfide linkages of the molecule and then alkylating the --SH groups. After the product was separated from the reaction mixture, it was sterilized. The so-produced material was intravenously injectable, substantially free from both actual and latent anticomplement activity, having substantially the biological half-life and spectrum of antibody activity of corresponding unmodified immune serum globulin.
Currently, there are several intravenously injectable gamma globulin products available outside the United States. One such product is INTRAGLOBIN of Biotest in Frankfurt. This product is made by beta-propriolactone treatment of gamma globulin (Stephan, Vox. Sang., 1975, Vol. 28, pp. 422-437). The material has a molar concentration of sodium ion of about 0.18 and of chloride of about 0.27. The beta-propiolactone used in its preparation is suspected as a carcinogen.
Another intravenously injectable product is manufactured by Green Cross Corporation of Japan (U.S. Pat. No. 4,168,303). It is a lyophilized, natural gamma globulin preparation having an anticomplementary activity of less than or equal to 20 C'H50 units and 0.06-0.26 parts by weight of a neutral mineral salt such as sodium chloride.
The Swiss Red Cross has an immunoglobulin SCR for intravenous administration. SCR contains more than 80% of monomeric IgG and minor fractions of dimeric, polymeric, and fragmented IgG as well as traces of IgA and IgM. The distribution of IgG subclasses equals that of normal serum. The product is manufactured in lyophilized form and contains 3 g of protein, 5 g of saccharose and a small quantity of sodium chloride per unit. A diluent (100 ml) contains 0.9% sodium chloride.
VENOGLOBULIN (Green Cross Corporation of Japan) is prepared by treating gamma globulin with plasmin. It also contains 0.5 parts of a protein stabilizer (e.g. amino acetate) per 1 part by weight of plasmin treated gamma globulin. The product is distributed as a white powder and is dissolved in a diluent for use. The resulting solution is clear or slightly turbid and has a pH of 6.4-7.4.
An intravenously injectable gamma globulin has been developed by Schwab of Germany and contains 50 mg per ml immunoglobulin, 7 mg/ml glycin, and 7 mg/ml sodium chloride.
Schura of Germany manufactures an intravenously injectable gamma globulin by adsorption onto hydroxyethyl starch. The product is distributed as a solution having a pH of 6.7 and a conductivity of 450 mosm. and containing 2.5% glucose, 165 meq/l of sodium ion and 120 meq/l of chloride ion.
VEINOGLOBULINE is available from Institute Merieux of France. It is a plasmin-treated gamma globulin distributed as a lyophilized powder containing 5 g. of protein and enough glycine and sodium chloride to insure pH and stability. The diluent is 100 ml of water for injection containing 0.9 g. of sodium chloride or isotonic glucose.
U.S. Pat. No. 4,160,763, assigned to Behringwerke AG of Germany, is directed to an immunoglobulin for intravenous administration having reduced complement fixation made by treating an immuno globulin fraction with a low concentration of a sulfitolytic agent and/or phosphate which is sparingly soluble in water. The pH of the material is 7.0, and the product contains 0.85% sodium chloride and 2.5% (g/v) glycine prior to lyophilization.
Teijin Institute of Tokyo is the assignee of record of U.S. Pat. No. 4,059,571 for a novel immunoglobulin derivative. A water soluble composition for intravenous injection which contains the novel derivative is described. The derivative is the S-sulfonated product of cleaved interchain disulfide bonds of gamma globulin.
GLOVENIN, a pepsin-treated human immunoglobulin, is manufactured by Nihon Seigaku of Japan. Typically, a solution of the above product contains 50 mg/ml of pepsin-treated immunoglobulin, 2.25% (w/v) of aminoacetic acid, and 0.85% (w/v) sodium chloride.
Yamanouch Seiyaku is the distributor of GLOBULIN V, a dried pepsin-treated human immunoglobulin (500 mg) containing 225 mg of aminoacetic acid and 85 mg of sodium chloride. For intravenous administration the dried product is disolved in 10 ml of water for injection.